Monitoring in the treatment of patients with aneurysmal and nonaneurysmal subarachnoid haemorrhage in terms of nursing care and therapy

Abstract

<jats:p>Cerebrovascular diseases together with cardiovascular and malignant diseases are the most common diseases in the developed world, regardless of the gender. They are at the third place as the cause of mortality and first as the cause of disability. Subarachnoid haemorrhage is a condition of discharging blood from cerebral arteries into the subarachnoid space within the brain. Subarachnoid haemorrhage (SAH) has a number of etiological features, but when it comes to spontaneous subarachnoid haemorrhage, in 80% of the cases it is caused by the rupture of an intracranial aneurysm. Subarachnoid haemorrhage (SAH) can be spontaneous and traumatic (post-traumatic). Also, it could be primary (direct bleeding into the subarachnoid space) or secondary (parenchymal bleeding to the subarachnoid space of the brain). Cerebral aneurysms are a local expansion in the blood vessel wall usually at the bifurcation of the artery. If cerebral artery ruptures and blood enters the subarachnoid space, the patient can have a very strong headache at the back and front part of the head. Short term memory can be affected as well. The initial assessment of patients should include: an overview of the quantitative state of mind, pupil size and reaction to light, motor and sensory function, the presence of headaches, dysfunction of cranial nerve (ptosis of the eyelids, difficulty moving eyes in all directions) blurred vision, aphasia, other neurological deficits). Several serious complications often arise after a successful operative treatment of the subarachnoid haemorrhage and aneurysm. One such complication is cerebral vasospasm, and is present in 50 to 70% of the patients. Late complications include recurrent bleeding, brain edema, chronic hydrocephalus and as most important - brain infarction. The incidence of subarachnoid haemorrhage ranges from 10-15/100 000 inhabitants. About 20% of the patients with spontaneous subarachnoid haemorrhage are younger than 45 years, while patients older than 70 years have a less positive prognosis of survival. Spontaneous subarachnoid haemorrhage is a disease of the middle age (55-60 years) with a relatively high mortality and morbidity. The prevalence of patients with an intracranial aneurysm is unknown, but it is assumed to be of higher incidence than subarachnoid haemorrhage. Approximately 10-15% of the patients die before they reach the physician, 10% die within the first few days, while the mortality rate in patients with all forms of subarachnoid haemorrhage is up to 45%. Morbidity is significant, considering that 66% of the patients never return to their earlier work, nor they have the same quality of life. Most patients with subarachnoid haemorrhage are subjected to a microneurosurgical treatment. In monitoring the patients and depending on the complications, but also in all situations, the role of nurses is primarily reflected in monitoring vital parameters and states of consciousness, and recognizing the signs and symptoms of neurological deterioration of the patient. Hypothesis. Patients with proper postoperative nursing care, monitoring and rehabilitation, with aneurysmal and nonaneurysmal subarachnoid haemorrhage, have fewer complications such as neurological deficits, pressure ulcers, nosocomial infections, changes in the values of the vital parameters and biohumoral status. Research Objectives. To show the total number of operated patients with confirmed subarachnoid haemorrhage at the Department of Neurosurgery, University of Sarajevo Clinical Centre during the period from 1 January 2013 to 31 December 2014. To show the ways in which the patients were monitored from admission to discharge from the Department. To show the stages of the patients’ progress along with the outcome of the treatment strategy. To show quality indicators (ventilator-associated pneumonia, nosocomial infections, pressure ulcers) in the test sample. Research Method. The research was a retrospective study. A descriptive analytical method was used which compared the data from the patient medical histories that included physicians and nurses’ notes for patients that were operated on at the Department of Neurosurgery, University of Sarajevo Clinical Centre. The sample included patients of both genders with a confirmed diagnosis of subarachnoid haemorrhage (aneurysma cerebri, haemorrhagia subarachnoidalis spontanea) who were operated on at the Department of Neurosurgery, University of Sarajevo Clinical Centre, in the period from 1 January 2013 to 31 December 2014. Of the 142 respondents, 93 or 65.5% were hospitalized for aneurysmal surgery and a control group of 49 of them, or 34.5%, were operated on for nonaneurysmal subarachnoid haemorrhage. There were 50.7% of men (n=72), and 49.3% of women (n=70). The participants in the study were of the average age of 54 years or 45-63.2 years. The study did not include the education and occupation of the participants. Criteria for inclusion into the study: Patients with a confirmed diagnosis of subarachnoid haemorrhage; patients operated on during the abovestated period; people older than 18 years. Criteria for exclusion from the study: Patients who were in the abovestated period diagnosed with the same illness and have not undergone surgery, but underwent conservative neuroradiological treatment (embolization). Results. Of the 142 respondents in the sample, 65.5% were hospitalized for aneurysmal surgery and 34.5% of the patients were operated for nonaneurysmal subarachnoid haemorrhage. The respondents were on average 54 years old. Men were on average 53 years and women 55 years old. Aneurysmal subarachnoid haemorrhage was more frequent among women (65.6%). The respondents with nonaneurysmal subarachnoid haemorrhage were older, 61 (43-62) years. Only 2% of the patients after aneurysm surgery were not under non-invasive monitoring, while the percentage of those with surgical treatment of nonaneurysmal subarachnoid haemorrhage was significantly higher at 24.5%. There was a fatal outcome in a total of 30 (32.6%) patients operated on for an aneurysm while the percentage of those who were operated on due to nonaneurysmal haemorraghe was lower and amounted to 4 (8.2%). Surviving patients, those with an aneurysm, on average stayed in hospital for 18 (12-24) days. Of the total number of patients operated for an aneurysm - 44 (47.3%) were independently mobile after surgery, 9 (9.7%) had limited mobility, 8 (8.6%) had very limited mobility and 32 (34.4%) were immobile. Most participants operated for subarachnoid haemorrhage were independently mobile after surgery 32 (65.3%), 10 (20.4%) had limited mobility, 3 (6.1%) had very limited mobility and only 4 (8.2%) were immobile. Of the entire sample with aneurysmal haemorrhage, ventilator-associated pneumonia was found in 9 patients (9.7%) who were operated for an aneurysm and in 2 patients (4.1%) after SAH surgery.</jats:p>